


Case Outline: Adam

by Grey_Bard



Category: Only Lovers Left Alive (2013)
Genre: Academia, Alternate Universe - Everyone Lives/Nobody Dies, Bipolar Disorder, Depression, Documentation, Fic with a Bibliography, Gen, Humor, POV Outsider, Psychologists & Psychiatrists, Vampires
Language: English
Status: Completed
Published: 2017-03-11
Updated: 2017-03-11
Packaged: 2018-10-02 04:46:17
Rating: Teen And Up Audiences
Warnings: No Archive Warnings Apply
Chapters: 1
Words: 3,625
Publisher: archiveofourown.org
Story URL: https://archiveofourown.org/works/10209914
Author URL: https://archiveofourown.org/users/Grey_Bard/pseuds/Grey_Bard
Summary: "Vampirism and depression does not have 1:1 linkage, as neither Eve, nor her sister Ava or their mutual vampire friend Christopher experience major depressive disorder."Or: Being Adam's therapist isreally hard, you guys.





	

**Author's Note:**

> Originally presented before an audience of an amused and in on the joke professor, and some very confused classmates in graduate school. The words "Wait, but... he thinks he's vampire?" kept coming up, even as I assured them that Adam indeed _was_ a vampire.

Case Outline: “Adam”

I am working at a fee for service mental health therapy clinic in Detroit. We offer therapy services from clinical social workers in conjunction with staff psychiatrists and case workers, as well as some outpatient drug treatment programs. Our patient population consists of long-time residents, mostly African-American, as well as some new residents of a variety of backgrounds who have been attracted by the underground art scene and low property prices. Depression, anxiety, PTSD, ADHD and substance use are our most common concerns. Most of our clients are low-income and our services are covered by Medicaid, but some clients are better off or not documented, and choose to pay through insurance or privately.

**Client Identifying Data**

Adam is a white British-born male who is married and appears to be in his 30's. He considers himself spiritual but not religious. When asked, he classifies his sexuality as “married to a woman”, but has implied that may he have had sexual encounters or flirtations with men in the past. He has a strong and supportive relationship with his wife, Eve, but their relationship had been in a long distance phase while she lived in Tangiers, Morocco, previous to his recent mental health crisis.

He is groomed, but casually dishevelled, which may be partly an aesthetic choice, or may simply be a decline in energy and interest. He dresses in an eccentric mixture of modern t-shirts and jeans and selected items of historical clothing, which makes his dishevelment appear to be a style choice. On closer inspection, however, apathy seems more likely. Adam's depression may have gone unnoticed because of his eccentricity. When interviewed, his affect was restricted and indifferent and he was laconic in response to most questions, although he could be articulate when he chose to speak at any length.

Adam's current DSM 5 diagnosis is 296.34: Major Depressive Disorder, severe recurrent episode. I still am attempting to rule out DSM 5 diagnosis 296.89, because Adam's unrevealing description of his behavior while in a non-depressed state could be describing mild hypomania, or perhaps simply higher enthusiasm and energy levels when not depressed. Until further evidence presents itself, however, his diagnosis must be Major Depressive Disorder. Nevertheless, the depth and frequent recurrence of his depression leads me to continue to suspect the possibility of Bipolar II. I have spoken to his psychiatrist on the subject, and he is monitoring Adam's moods and medication accordingly.

**Presenting Concerns**

Adam came for therapy because he feels depressed and had recently been experiencing suicidal ideation, and was mid suicide-attempt before he called his wife for help. He had gone as far as acquiring ammunition from a friend for the attempt, and aiming the weapon. His wife reports that despite his love of tinkering and home repair, he has neglected many minor home repair tasks, and his home has slid from cluttered to dirty over the course of his depression. He has missed out on professional opportunities, isolating himself at home, refusing to play his music live, or even promote his recordings in any way.

Adam has isolated himself from the community around him, interacting only with his closest friend and unofficial manager, Ian, who has been helping him with basic tasks such as shopping as well as distributing his music, and Eve. As soon as she heard about his suicide attempt, Eve returned from Morocco to care for him. Adam has no living family, because he is a vampire and was born shortly before the English Civil War. This has limited his support system, not only because his family has predeceased him, but also because vampires are a rare subculture, and he cannot go outside during the day.

**Relevant History**

Adam was born in 1602 to an English clergyman and musician, and given a musical education alongside his brother. He had a stable family life and was happy to go into the family business - music. However, his family’s fortunes were heavily entangled in the British royal court where he found work as a composer, and there was social unrest against the king.

Adam did not experience substance abuse as part of his family environment growing up, but many of the artists and musicians who he knew and cared about over his lifetime struggled with substance abuse, which troubled him. He reports that he has difficulty knowing his family mental health history, because there were no mental health diagnoses or professions at that time as we know them now. Adam does not exhibit any problematic substance use behavior himself, but he has an unhealthy relationship with food - in his case, blood. (He obtains his blood ethically, in a non-violent manner.) When he is particularly depressed he reports that he frequently does not eat, to the point that his wife has expressed serious concerns for his health.

Adam has been married to Eve for over two hundred years, and is monogamous with the exception of rare sexual encounters between himself, his wife, and a third party. Sometimes they choose to live apart for a time because Eve wishes to travel more widely than her husband, but they keep in close contact by phone and video chat. At the beginning of Adam’s current depression, Eve was living in Tangiers. He considers her to be the most important person in his life, and his most important source of support. Adam has implied he has had romantic and sexual experiences before his marriage, but declines to share further information, saying it is irrelevant and private.

Adam fought in the English Civil War on the Royalist side, during which he died and became a vampire. While he survived, he lost his friends and family, who believed him dead, and witnessed the death and carnage of the battlefield and the divisive social unrest that comes with civil war. He also had to cope with the experience of nearly dying, and adjusting to a secretive way of life that requires one to ingest human blood, all of which was traumatic for him.

Adam reports that it had been decades since he had experienced suicidal ideation as intense as that which he experienced during his current bout of depression, but he has had regularly recurring periods of depression throughout his adult life, since before he became a vampire. (Vampirism and depression does not have 1:1 linkage, as neither Eve, nor her sister Ava or their mutual vampire friend Christopher experience major depressive disorder.) Both Adam and his wife Eve were born before the era of modern mental health treatment, and so it was strange to either of them to seek help for him from a therapist. Adam did have one previous attempt at therapy in the past, with a Freudian psychoanalyst in the 1930’s, but he found this unhelpful, and has not sought professional help in the years since. He states that he has had five near or partial suicide attempts in the past four hundred years. Despite the commonly assumed predatory nature of vampires, Adam states that he has never experienced homicidal ideation.

Adam admits to a history of exhibiting self-injurious behavior when extremely depressed, in the form of allowing parts of his skin to be burned by the sun for very short periods of time (a serious business for vampires). He also has engaged in self destructive and risk-taking behavior such as or traveling without securing a sufficient food source ahead of time, or failing to secure windows fully against the sun.

**Relevant Current Information**

Adam lives in a previously abandoned Victorian-era home in Detroit. Although Adam is an enthusiastic amateur tinker and inventor who has rewired his home to work on renewable energy, he has been recently been neglecting his home. He believed the refrigerator was broken, and did without it, until his wife came to visit and pointed out that it was simply unplugged. Ian noticed that one of his toilets has gone unfixed for months. The house had become quite dirty, and it is possible that if he were left there entirely alone, his home might become an unsafe environment.

Adam is a professional musician and has some income coming in from recordings he has published recently under a pseudonym, as well as significant savings from previous employment.

Adam’s support system currently consists of his wife Eve, and his friend and manager, Ian. He also has a living vampire sister in-law, Ava, with whom he does not get along, and a longtime vampire friend, Christopher, who lives in Tangiers and he sees only rarely. When Ava is visiting, as she currently is, she is a significant source of stress to Adam. She wastes his blood, stays out all night partying, and exhibits poor judgement, making him feel uncomfortable in his own home. Adam also feels stressed by the fact that a number of music enthusiasts have discovered where he lives, and sometimes come by to gawk at the home of such a mysterious recluse.

**Assessment of Strengths and Needs**

Using the Strengths, Needs, Abilities and Preferences template as a starting point, it becomes clear that Adam has a number of valuable resources that could stand him in good stead as he recovers, and contribute to resiliency. He also has a number of very individual needs which need to be taken into account. Adam’s strengths include his curiosity and interest in the world around him, his creativity and resourcefulness, his strong and supportive relationship with his wife and the fact that when he hit his lowest point, he was willing and able to reach out and seek help. His abilities include his ability to form and maintain strong, lasting relationships, his skill as a musician and composer, and his skills as an amateur inventor.

Adam’s needs include a need for psychoeducation to help him understand his condition in the context of our modern knowledge about mental health, a need - and desire - for therapy, and of course he needs all of these support and therapy services to be available to him after sunset. He also needs a wider network of emotional support than simply his wife and one friend. Adam’s preferences include a preference for discretion and privacy, a preference toward evidence-based practice and a more scientific and less spiritual language surrounding therapy, and a desire to be kept fully informed and included in his own treatment, respectfully and without patronization.

**Systems Illustrations**

 

**Ecomap**

Adam lives in Detroit, and is a musician, but his relationship with both Detroit and the Detroit musical community is tenuous at best at the moment. He prefers to isolate himself at home and record music alone, going out only for food and necessities. Adam has a strong connection to his friend Ian, and Ian serves as his connection to the outside world. Ian serves as his agent, taking the care of all the details of releasing his music, and provides him with items not easily found in 24-hour stores. Ian also is Adam’s only contact with admirers of his music, because Adam dislikes the very idea of notoriety.

Eve is another one of Adam’s deep, intense connections. They have been married for over two hundred years, and not only is she personally a support for him, she also connects him to the larger world of other vampires. Eve is older than Adam, more willing to travel, and it is through her that he knows and keeps in touch with the vampires Christopher and Ava.

Finally, Adam’s last deep relationship is with music itself. It has been a steady and powerful influence throughout all the turmoil and changes of his lifetime, since his childhood. Even at the worst of times, Adam can still enjoy and lose himself in music.

**Cycle of Self-Isolation**

Adam often doubts his ability to get along with or care about with non-vampire humans because they are so different, referring to them as “zombies”, even, indeed particularly, his own fans. This, then, becomes his rationale for self isolation, as seen in the diagram. He does not know them, and when he is depressed he tends to assume that they must have nothing in common. Therefore, he usually avoids socializing when he is depressed. As a result of this belief, he stays home and isolates himself further in his crumbling house. This, then, is depressing, so it all starts again. However, this belief of Adam’s is directly contradicted by his bond with Ian, and the many human friends he remembers fondly from the course of his vampiric lifespan.

**Case Formulation/Clinical Impressions**

Adam is conflicted between his need for human contact and his self-imposed reflexive distance to avoid disappointment and loss similar to those he experienced in the past. Evidence for this can be seen in the way he scornfully dismisses most people he does not know as “zombies”, and sometimes literally hides from them in disgust, in contrast to the way in which he romanticizes the memory of friends who are now dead and cannot disappoint him, Also, his depression-based apathy encourages his isolation, which in turn is depressing to him.

Adam's career and financial situation, while not optimal during his hermit phase, allows him to maintain his isolated life during his depressive swings. While his financial well-being is a good thing, the spur of survival is not there to encourage him to leave the home. Alternately, perhaps he would still isolate himself at these times, but simply enter extreme poverty. The age of his home and its need for constant upkeep mean that his standard of living can degrade very quickly during a depressive episode if he is living alone. He is stressed by his isolation, but also by the real differences between our modern era and the quieter world he grew up in. Some useful modern coping strategies – such as seeking mental health treatment, take years, even decades, for him to adopt.

Adam is moving back and forth somewhere between the preparation and action stages of change, because while he has sought out a therapist and begun a course of therapy, he dropped out of his first treatment intervention, and still has some ambivalent feelings toward action, even as he begins it. Adam varies in his level of motivation – he appears to sincerely not wish to feel depressed, but he is skeptical of therapy, and it is difficult for him to feel motivation at all when he is extremely depressed.

**Treatment Plan**

**Goals**

In Adam's words he wants to “...Stop feeling like a lead weight. Stop wanting to die.” In discussion with Adam, I confirmed that he meant that his ultimate treatment goal is to experience full recovery from his depression, but his most important and immediate short term goal is a remission of suicidal ideation. Success would be measured by achieving at least a 3 point reduction on the Hamilton depression scale.

**Objectives**

Adam's original short term objective was to achieve twenty minutes of mindfulness meditation per day, and to leave the house once, for a period of over twenty minutes, per day. This was arrived at through discussion with Adam about mindfulness as a possible intervention, and based upon Adam's admission that not leaving the house was “probably too Gothic to be safe”. Twenty minutes was arrived at as an amount of time short enough to be bearable, but long enough to do something productive. Because Adam chose to discontinue the mindfulness intervention, and took my suggestion of DBT therapy instead, his objectives needed to change as well. Adam's new short term objective is to leave the house once, for a period of over twenty minutes, per day, and participate in an entire course of group DBT therapy for the full six month term. At the end of this time we will reevaluate his score on the Hamilton depression scale, and Adam will decide whether or not he wishes to continue treatment and how. I am continuing to ask about suicidal ideation at each session, and tracking his progress.

**Arriving at Treatment Plan**

As a non-mandated, purely voluntary client in an outpatient clinical setting, Adam was able to fully take part in treatment planning without conflicting institutional interests. However, Adam's manner was distant and sardonic for most of the treatment planning discussion, as he was being cautious and not fully emotionally investing in therapy yet. Adam was very intellectually curious about possible treatment options, but skeptical about applying them to himself. I suggested a number of popular evidence-based interventions for major depression and he selected mindfulness almost at random, I felt.

**Interventions**

My style of establishing rapport is to be as low-key and conversational as possible, offering tea to clients, acknowledging their distress, and matter of factly offering treatment options. Adam does not drink tea, being a vampire, and said that he felt my offer showed insufficient research. He did respond well to the consumer model of therapy, although he was very skeptical about its possible benefits.

**Mindfulness-based Cognitive Therapy**

A cognitive approach seemed appropriate for Adam, because his chief conflicts were largely internal, as opposed to systems or environmental driven, and its scientific-esque concreteness was appealing to him. There is significant evidence to suggest that the intervention Mindfulness-based Cognitive Therapy is often effective in reducing suicidality in people experiencing Major Depression (Barnhofer et al., 2015). However, after three weeks of mindfulness meditation practice, Adam stated that he felt this therapy was counterproductive. He reported that clearing his mind led to a greater number of intrusive thoughts about the depravity of human nature and the plight of the environment. He said that just when he was “really relaxed” it “hit” him. Adam was not receptive to pushing past this barrier, and inquired about other forms of therapy.

**DBT and Group Therapy**

I suggested Internet-based Cognitive Behavioral Therapy (ICBT) to Adam, both because it has been found to be effective for Major Depression (Mewton, & Andrews, 2015) and because I felt it would be non-threatening to an isolated man, but he disagreed. To him, therapy on the internet seemed like “wasting time”. With his goal of reducing suicidal ideation, our DBT program seemed like a good fit, as it is a evidence-based intervention for suicidality, particularly since it might also work well if he has Bipolar II (Chesin & Stanley, 2013). Although DBT is often thought of as a treatment for Borderline Personality Disorder, it was actually originally designed as a therapy to target and reduce recurring suicidality of all kinds (Meygoni & Ahadi, 2012). Group therapy is an integral part of DBT treatment, and I felt this would have the benefit of helping to break Adam's isolation by putting him in contact with a group of people suffering similarly. Adam has attended two sessions and seems hopeful.

**Termination**

Because Adam is a self-referred voluntary client who is paying out of pocket, there is no hard and fast deadline for termination. However, Adam does not wish to continue treatment indefinitely, nor should he. Adam has agreed to take part in an entire six month course of DBT therapy, both individual and group. He also will continue to take psychiatric medication as directed by his in-house psychiatrist, which will be monitored and adjusted as necessary. At the end of this time, Adam has said that if he is either satisfied with his progress, or chooses to move on to a different treatment provider, we will terminate the therapeutic relationship. If at any time Adam feels his suicidal ideation is worsening or reaching another crisis point, an emergency reevaluation will be necessary,.

**Concern**

We talk about reality testing and reframing, but what do you say to someone who wants to be less depressed, but has a rational yet depressing worldview? Adam has had a lot of experience with loss, and he knows he is going to experience more. He’s become embittered by seeing people that he respected treated badly by society when it does not understand them. He has a dark view of human nature which he sincerely believes, and which is grounded in his personal experience.

Based on historical trends, his own historical experiences, and ecology, Adam also believes that once mankind stops fighting over oil, society will devolve into a series of terrible wars over water. While eccentric, this belief is based on real - if highly circumstantial - evidence, and he is convinced of it. How do you work around depressing yet rational beliefs without saying “you’re wrong”, or giving up? How do you tease out the cognitions and cognitive distortions that can be challenged successfully in a sensitive and respectful manner?

**References**

Barnhofer, T., Crane, C., Brennan, K., Duggan, D. S., Crane, R. S., Eames, C., & ... Williams, J. G. (2015). Mindfulness-based cognitive therapy (MBCT) reduces the association between depressive symptoms and suicidal cognitions in patients with a history of suicidal depression. _Journal Of Consulting And Clinical Psychology_ , _83_ (6), 1013-1020. doi:10.1037/ccp0000027

Chesin, M., & Stanley, B. (2013). Risk assessment and psychosocial interventions for suicidal patients. _Bipolar Disorders_ , _15_ (5), 584-593. doi:10.1111/bdi.12092

Mewton, L., & Andrews, G. (2015). Research report: Cognitive behaviour therapy via the internet for depression: A useful strategy to reduce suicidal ideation. _Journal Of Affective Disorders_ , _170_ 78- 84. doi:10.1016/j.jad.2014.08.038

Meygoni, A. M., & Ahadi, H. (2012). Declining the rate of Major Depression: Effectiveness of Dialectical Behavior Therapy. _Procedia - Social And Behavioral Sciences_ , _35_ (AicE-Bs 2011 Famagusta (Asia Pacific International Conference on Environment-Behaviour Studies, Salamis Bay Conti Resort Hotel, Famagusta, North Cyprus, 7-9 December 2011), 230-236. doi:10.1016/j.sbspro.2012.02.083

Michalak, J., Schultze, M., Heidenreich, T., & Schramm, E. (2015). A randomized controlled trial on the efficacy of mindfulness-based cognitive therapy and a group version of behavioral analysis system of psychotherapy for chronically depressed patients. _Journal Of Consulting And Clinical Psychology_ , _83_ (5), 951-963. doi:10.1037/ccp0000042

 


End file.
